Volume 10, Issue 39, October 16, 2018

CDC Science Clips: Volume 10, Issue 39, October 16, 2018

Science Clips is produced weekly to enhance awareness of emerging scientific knowledge for the public health community. Each article features an Altmetric Attention scoreExternal to track social and mainstream media mentions!

  1. Top Articles of the Week

    Selected weekly by a senior CDC scientist from the standard sections listed below.

    The names of CDC authors are indicated in bold text.
    • Communicable Diseases
      • Going off grid: Modeling an automated record search to process electronically reported reactive nontreponemal syphilis testsExternal
        Matthias J, Keller G, Cha S, Wilson C, Peterman TA.
        Sex Transm Dis. 2018 Oct;45(10):655-659.

        BACKGROUND: Before searching prior records, sexually transmitted disease programs use syphilis reactor grids to exclude some reactive nontreponemal test results (RNTs) based on patient age, gender, and test titer. We propose a new algorithm that starts with comparing RNTs to previous syphilis nontreponemal tests and current treponemal test results. METHODS: Deduplicated RNTs from Florida’s surveillance system (2006-2015) were extracted and stratified on morbidity. An algorithm was developed to triage RNTs. Sensitivity and specificity of the algorithm and the current reactor grid were estimated using reported syphilis cases. A random sample of cases missed by the proposed algorithm, stratified by stage of disease, was reviewed to verify case classification. RESULTS: Reported RNTs increased 58% from 2006 (n = 34,808) to 2015 (n = 55,001) (total = 372,902). The current reactor grid removed 91,518 (24.5%) RNTs and missed 1149 potential cases. Strictly following the reactor grid would result in a sensitivity of 97.4% and a specificity of 27.5%. The proposed algorithm would remove 242,078 (64.9%) RNTs and miss 2768 potential cases. This results in a slightly lower sensitivity of 93.8%, but nearly triples the specificity, 72.9%. A review of a random sample of the 2768 cases estimated that 72.7% would not have met the syphilis surveillance case definition, resulting in an adjusted sensitivity of 98.4%. CONCLUSIONS: In Florida, an algorithm that starts by searching previous syphilis test results vastly improved specificity and slightly improved sensitivity compared with the current reactor grid. Implementing an automated algorithm could increase case ascertainment efficiency and further prioritize likely cases for investigation.

    • Environmental Health
      • Age-specific associations of ozone and PM2.5 with respiratory emergency department visits in the USExternal
        Strosnider HM, Chang HH, Darrow LA, Liu Y, Vaidyanathan A, Strickland MJ.
        Am J Respir Crit Care Med. 2018 Oct 2.

        RATIONALE: While associations between air pollution and respiratory morbidity for adults 65 and older are well-documented in the United States, the evidence for people under 65 is less extensive. To address this gap, the Centers for Disease Control and Prevention’s National Environmental Public Health Tracking Program collected respiratory emergency department (ED) data from 17 states. OBJECTIVES: Estimate age-specific acute effects of ozone and fine particulate matter (PM2.5) on respiratory ED visits. METHODS: We conducted time-series analyses in 894 counties by linking daily respiratory ED visits with estimated ozone and PM2.5 concentrations during the week before the date of the visit. Overall effect estimates were obtained using a Bayesian hierarchical model to combine county estimates for each pollutant by age group (children 0-18, adults 19-64, adults >/=65, and all ages) and by outcome group (acute respiratory infection, asthma, chronic obstructive pulmonary disease, pneumonia, and all respiratory ED visits). MEASUREMENTS AND MAIN RESULTS: Rate ratios (95% credible interval) per 10 microg/m3 increase in PM2.5 and all respiratory ED visits were 1.024 (1.018, 1.029) among children, 1.008 (1.004, 1.012) among adults <65, and 1.002 (0.996, 1.007) among adults 65 and older. Per 20 ppb increase in ozone, rate ratios were 1.017 (1.011, 1.023) among children, 1.051 (1.046, 1.056) among adults <65, and 1.033 (1.026, 1.040) among adults 65 and older. Associations varied in magnitude by age group for each outcome group. CONCLUSIONS: These results address a gap in the evidence used to ensure adequate public health protection under national air pollution policies.

    • Health Behavior and Risk
      • Nonconforming gender expression and associated mental distress and substance use among high school studentsExternal
        Lowry R, Johns MM, Gordon AR, Austin SB, Robin LE, Kann LK.
        JAMA Pediatr. 2018 Sep 24.

        Importance: The cultural roles and expectations attributed to individuals based on their sex often shape health behaviors and outcomes. Gender nonconformity (GNC) (ie, gender expression that differs from societal expectations for feminine or masculine appearance and behavior) is an underresearched area of adolescent health that is often linked to negative health outcomes. Objective: To examine the associations of GNC with mental distress and substance use among high school students. Design, Setting, and Participants: Cross-sectional study based on data from the Youth Risk Behavior Survey (YRBS) conducted in 2015. The setting was 3 large urban US school districts (2 in California and 1 in Florida). Participants were a racially/ethnically diverse population-based sample of 6082 high school students representative of all public school students in grades 9 through 12 attending these 3 school districts. Main Outcomes and Measures: Sex-stratified adjusted prevalence ratios (APRs) (adjusted for race/ethnicity, grade, and sexual identity) for high gender-nonconforming students (very/mostly/somewhat feminine male students or very/mostly/somewhat masculine female students) and moderate gender-nonconforming students (equally feminine and masculine students) relative to a referent group of low gender-nonconforming students (very/mostly/somewhat masculine male students or very/mostly/somewhat feminine female students). Results: Among 6082 high school students, 881 (15.9%) were white, 891 (19.1%) black, 3163 (55.1%) Hispanic, and 1008 (9.9%) other race/ethnicity. Among female students (2919 [50.0% of the study population]), moderate GNC was significantly associated with feeling sad and hopeless (APR, 1.22; 95% CI, 1.05-1.41), seriously considering attempting suicide (APR, 1.41; 95% CI, 1.14-1.74), and making a suicide plan (APR, 1.52; 95% CI, 1.22-1.89); however, substance use was not associated with GNC. Among male students (3139 [50.0% of the study population]), moderate GNC was associated with feeling sad and hopeless (APR, 1.55; 95% CI, 1.25-1.92); high GNC was associated with seriously considering attempting suicide (APR, 1.72; 95% CI, 1.16-2.56), making a suicide plan (APR, 1.79; 95% CI, 1.17-2.73), and attempting suicide (APR, 2.78; 95% CI, 1.75-4.40), as well as nonmedical use of prescription drugs (APR, 1.81; 95% CI, 1.23-2.67), cocaine use (APR, 2.84; 95% CI, 1.80-4.47), methamphetamine use (APR, 4.52; 95% CI, 2.68-7.61), heroin use (APR, 4.59; 95% CI, 2.48-8.47), and injection drug use (APR, 8.05; 95% CI, 4.41-14.70). Conclusions and Relevance: This study suggests mental distress is associated with GNC among female and male students. Substance use also appeared to be strongly associated with GNC among male students. These findings underscore and suggest the importance of implementing school-based programs to prevent substance use and promote student mental health that are inclusive of gender diversity in students.

    • Laboratory Sciences
      • Predicting nanotube fibrogenicity through stem cell-mediated fibroblast focus and spheroid formationExternal
        He X, Kiratipaiboon C, Porter DW, Rojanasakul LW, Dinu CZ, Wang K, Yang Y, Rojanasakul Y.
        Nano Lett. 2018 Sep 19.

        Fibroblast stem cells or stemlike cells (FSCs) are proposed to play a pivotal role in extracellular matrix (ECM) regeneration by serving as a key source of ECM-producing fibroblasts. We developed a mechanism-based in vitro model for fibrogenicity testing of nanomaterials based on their ability to induce FSCs. Using a FSC-enriched fibroblast focus model to mimic in vivo fibrogenic response, we demonstrated a dose-dependent increase in fibroblast focus formation and collagen production by primary lung fibroblasts treated with multiwalled carbon nanotubes (MWCNTs). The focus-forming cells exhibited stem properties as indicated by stem cell markers expression, sphere formation, and ALDH activity assays. Inhibition of ALDH activity diminished the focus and sphere formation as well as collagen production. In vivo animal studies supported the in vitro findings and indicated the potential utility of FSC-based assays as a rapid screening tool for fibrogenicity testing of nanomaterials. This study also unveils a novel mechanism of nanotube-induced fibrogenesis through ALDH-dependent FSC activation.

      • Nuts and bolts of protein quantification by online trypsin digestion coupled LC-MS/MS analysisExternal
        Toth CA, Kuklenyik Z, Barr JR.
        Methods Mol Biol. 2019 ;1871:295-311.

        Protein digestion coupled to liquid chromatography and tandem mass spectrometry (LC-MS/MS) detection enables multiplexed quantification of proteins in complex biological matrices. However, the reproducibility of enzymatic digestion of proteins to produce proteotypic target peptides is a major limiting factor of assay precision. Online digestion using immobilized trypsin addresses this problem through precise control of digestion conditions and time. Because online digestion is typically for a short time, the potential for peptide degradation, a major source of measurement bias, is significantly reduced. Online proteolysis requires minimal sample preparation and is easily coupled to LC-MS/MS systems, further reducing potential method variability. We describe herein a method optimized for the multiplexed quantification of several apolipoproteins in human serum using on-column digestion. We highlight key features of the method that enhance assay accuracy and precision. These include the use of value-assigned serum as calibrators and stable isotope-labeled (SIL) peptide analogs as internal standards. We also comment on practical aspects of column switching valve design, instrument maintenance, tandem mass spectrometry data acquisition, and data processing.

    • Occupational Safety and Health
      • Skin cancer and weldingExternal
        Falcone LM, Zeidler-Erdely PC.
        Clin Exp Dermatol. 2018 Oct 2.

        Many workers in several different occupations can be exposed to ultraviolet radiation (UVR), which may increase their risk of developing skin cancer. Welding, an occupation employing an estimated 11 million people worldwide, is one such occupation. Welders are known to be exposed to the full spectrum of UVR from the welding arc and often experience burns and localized cutaneous erythema. In 2017, UVR from welding was classified as carcinogenic to humans based on sufficient evidence of ocular melanoma in humans. It has been hypothesized that exposure to UVR from the welding arc also may increase the risk of skin cancer among workers in this occupation. This review summarizes the current literature on skin cancer risk in welders.

    • Parasitic Diseases
      • Evidence of likely autochthonous transmission of Chagas disease in ArizonaExternal
        Beatty NL, Perez-Velez CM, Yaglom HD, Carson S, Liu E, Khalpey ZI, Klotz SA, Elliott SP.
        Am J Trop Med Hyg. 2018 Oct 1.

        A healthy 16-year-old girl born and raised in Tucson, AZ, had screening and confirmatory testing revealing Chagas disease; clinical evaluation established that she had the indeterminate form of chronic Chagas disease with evidence of likely autochthonous transmission. Trypanosoma cruzi DNA was detected by conventional PCR in Triatoma rubida captured at her home.

      • Population genetic analysis of Chadian Guinea worms reveals that human and non-human hosts share common parasite populationsExternal
        Thiele EA, Eberhard ML, Cotton JA, Durrant C, Berg J, Hamm K, Ruiz-Tiben E.
        PLoS Negl Trop Dis. 2018 Oct 4;12(10):e0006747.

        Following almost 10 years of no reported cases, Guinea worm disease (GWD or dracunculiasis) reemerged in Chad in 2010 with peculiar epidemiological patterns and unprecedented prevalence of infection among non-human hosts, particularly domestic dogs. Since 2014, animal infections with Guinea worms have also been observed in the other three countries with endemic transmission (Ethiopia, Mali, and South Sudan), causing concern and generating interest in the parasites’ true taxonomic identity and population genetics. We present the first extensive population genetic data for Guinea worm, investigating mitochondrial and microsatellite variation in adult female worms from both human and non-human hosts in the four endemic countries to elucidate the origins of Chad’s current outbreak and possible host-specific differences between parasites. Genetic diversity of Chadian Guinea worms was considerably higher than that of the other three countries, even after controlling for sample size through rarefaction, and demographic analyses are consistent with a large, stable parasite population. Genealogical analyses eliminate the other three countries as possible sources of parasite reintroduction into Chad, and sequence divergence and distribution of genetic variation provide no evidence that parasites in human and non-human hosts are separate species or maintain isolated transmission cycles. Both among and within countries, geographic origin appears to have more influence on parasite population structure than host species. Guinea worm infection in non-human hosts has been occasionally reported throughout the history of the disease, particularly when elimination programs appear to be reaching their end goals. However, no previous reports have evaluated molecular support of the parasite species identity. Our data confirm that Guinea worms collected from non-human hosts in the remaining endemic countries of Africa are Dracunculus medinensis and that the same population of worms infects both humans and dogs in Chad. Our genetic data and the epidemiological evidence suggest that transmission in the Chadian context is currently being maintained by canine hosts.

    • Substance Use and Abuse
    • Zoonotic and Vectorborne Diseases

  2. CDC Authored Publications
    The names of CDC authors are indicated in bold text.
    Articles published in the past 6-8 weeks authored by CDC or ATSDR staff.
    • Chronic Diseases and Conditions
      1. Multilevel regression for small-area estimation of mammography use in the United States, 2014External
        Berkowitz Z, Zhang X, Richards TB, Sabatino SA, Peipins LA, Holt J, White MC.
        Cancer Epidemiol Biomarkers Prev. 2018 Oct 1.

        BACKGROUND: The US Preventive Services Task Force recommends biennial screening mammography for average-risk women aged 50 to 74 years. County-level information on population measures of mammography use can inform targeted intervention to reduce geographic disparities in mammography use. County-level estimates for mammography use nationwide are rarely presented. METHODS: We used data from the 2014 Behavioral Risk Factor Surveillance System (BRFSS) (n=130,289 women), linked it to the American Community Survey poverty data, and fitted multilevel logistic regression models with two outcomes: mammography within the past 2 years (up-to-date); and most recent mammography 5 or more years ago or never (rarely/never). We post-stratified the data with US Census population counts to run Monte Carlo simulations. We generated county-level estimates nationally and by urban-rural county classifications. County-level prevalence estimates were aggregated into state and national estimates. We validated internal consistency between our model-based state-specific estimates and urban-rural estimates with BRFSS direct estimates using Spearman correlation coefficients and mean absolute differences. RESULTS: Correlation coefficients were 0.94 or larger. Mean absolute differences for the 2 outcomes ranged from 0.79 to 1.03. Although 78.45% (95% CI: 77.95% horizontal line 78.92%) of women nationally were up-to-date with mammography, more than half of the states had counties with >15% of women rarely/never using a mammogram, many in rural areas. CONCLUSIONS: We provided estimates for all U.S. counties and identified marked variations in mammography use. Many states and counties were far from the 2020 target (81.1%). IMPACT: Our results suggest a need for planning and resource allocation on a local level to increase mammography uptake.

      2. Symptoms of anxiety and depression among adults with arthritis – United States, 2015-2017External
        Guglielmo D, Hootman JM, Boring MA, Murphy LB, Theis KA, Croft JB, Barbour KE, Katz PP, Helmick CG.
        MMWR Morb Mortal Wkly Rep. 2018 Oct 5;67(39):1081-1087.

        An estimated 54.4 million (22.7%) U.S. adults have doctor-diagnosed arthritis (1). A report in 2012 found that, among adults aged >/=45 years with arthritis, approximately one third reported having anxiety or depression, with anxiety more common than depression (2). Studies examining mental health conditions in adults with arthritis have focused largely on depression, arthritis subtypes, and middle-aged and older adults, or have not been nationally representative (3). To address these knowledge gaps, CDC analyzed 2015-2017 National Health Interview Survey (NHIS) data* to estimate the national prevalence of clinically relevant symptoms of anxiety and depression among adults aged >/=18 years with arthritis. Among adults with arthritis, age-standardized prevalences of symptoms of anxiety and depression were 22.5% and 12.1%, respectively, compared with 10.7% and 4.7% among adults without arthritis. Successful treatment approaches to address anxiety and depression among adults with arthritis are multifaceted and include screenings, referrals to mental health professionals, and evidence-based strategies such as regular physical activity and participation in self-management education to improve mental health.

      3. BACKGROUND: Lung cancer is the leading cause of cancer-related deaths in the United States, and radon exposure is the second leading risk factor. Fewer than 25% of existing U.S. homes have been tested for radon, and only 5-10% of new homes use some form of radon prevention. OBJECTIVE: This qualitative study sought to determine radon-related knowledge, attitudes, and practices among Realtors to inform cancer control activities at local and state levels. METHODS: We conducted focus groups with Realtors in four states to collect information about knowledge, attitudes, and practices regarding radon. RESULTS: Realtors reported obtaining information on radon in similar ways, being aware of radon and its characteristics, and dealing with radon issues as a normal part of home sales. Differences in attitudes toward testing varied across states. Realtors in states with radon policies generally expressed more positive attitudes toward testing than those in states without policies. Radon mitigation was identified as an added expense to buyers and sellers. Realtors cited concerns about the reliability and credibility of mitigation systems and installers. CONCLUSIONS: These findings suggest that attitudes and practices vary among Realtors and that additional educational resources about radon as a cancer risk factor may be beneficial. When comprehensive cancer control programs update their plans, they may want to add objectives, strategies, or activities to reduce radon exposure and prevent lung cancer. These activities could include partnering with Realtors to improve their knowledge, attitudes, and practices about radon, as well as developing and distributing radon educational resources.

    • Communicable Diseases
      1. Psychrobacter sanguinis wound infection associated with marine environment exposure, Washington, USAExternal
        Bonwitt J, Tran M, Droz A, Gonzalez A, Glover WA.
        Emerg Infect Dis. 2018 Oct;24(10):1942-1944.

        We report a 26-year-old man with Psychrobacter sanguinis cellulitis of a wound sustained during ocean fishing in Washington, USA, in 2017. Psychrobacter spp. are opportunistic pathogens found in a wide range of environments. Clinicians should be aware of Psychrobacter spp. and perform 16S rRNA sequencing if this pathogen is suspected.

      2. Reactor grids for prioritizing syphilis investigations: Are primary syphilis cases being missed?External
        Cha S, Matthias JM, Rahman M, Schillinger JA, Furness BW, Pugsley RA, Kidd S, Bernstein KT, Peterman TA.
        Sex Transm Dis. 2018 Oct;45(10):648-654.

        BACKGROUND: Health departments prioritize investigations of reported reactive serologic tests based on age, gender, and titer using reactor grids. We wondered how reactor grids are used in different programs, and if administratively closing investigations of low-titer tests could lead to missed primary syphilis cases. METHODS: We obtained a convenience sample of reactor grids from 13 health departments. Interviews with staff from several jurisdictions described the role of grids in surveillance and intervention. From 5 jurisdictions, trends in reactive nontreponemal tests and syphilis cases over time (2006-2015) were assessed by gender, age, and titer. In addition, nationally-reported primary syphilis cases (2013-2015) were analyzed to determine what proportion had low titers (</=1:4) that might be administratively closed by grids without further investigation. RESULTS: Grids and follow-up approaches varied widely. Health departments in the study received a total of 48,573 to 496,503 reactive serologies over a 10-year period (3044-57,242 per year). In 2006 to 2015, the number of reactive serologies increased 37% to 169%. Increases were largely driven by tests for men although the ratios of tests per reported case remained stable over time. Almost one quarter of reported primary syphilis had low titers that would be excluded by most grids. The number of potentially missed primary syphilis cases varied by gender and age with 41- to 54-year-old men accounting for most. CONCLUSIONS: Reactor grids that close tests with low titers or from older individuals may miss some primary syphilis cases. Automatic, computerized record searches of all reactive serologic tests could help improve prioritization.

      3. Tenofovir exposure during pregnancy and postpartum in women receiving tenofovir disoproxil fumarate for the prevention of mother-to-child transmission of hepatitis B virusExternal
        Cressey TR, Harrison L, Achalapong J, Kanjanavikai P, Patamasingh Na Ayudhaya O, Liampongsabuddhi P, Siriwachirachai T, Putiyanun C, Suriyachai P, Tierney C, Salvadori N, Chinwong D, Decker L, Tawon Y, Murphy TV, Ngo-Giang-Huong N, Siberry GK, Jourdain G.
        Antimicrob Agents Chemother. 2018 Oct 1.

        We assessed tenofovir exposure during pregnancy and postpartum in hepatitis B virus (HBV)-infected, HIV-uninfected, women receiving tenofovir disoproxil fumarate (TDF) to prevent mother-to-child transmission of HBV. Data from 154 women who received TDF within a randomized-controlled trial were included. Individual plasma tenofovir exposures (AUC0-24) were estimated using a population pharmacokinetic approach. Estimated geometric mean tenofovir AUC0-24 was 20% (95% CI: 19-21%) lower during pregnancy compared to postpartum; this modest reduction in the absence of HBV transmission suggests no dose adjustment is needed.

      4. Sexual health education, including HIV prevention information, can help prevent unintended pregnancy and sexually transmitted infections. National Youth Risk Behavior Survey data from 2011 and 2013 were used to determine HIV education prevalence among 9,825 currently sexually active students in grades 9-12. Associations between HIV education and contraceptive methods used at last sexual intercourse were examined for: (1) condom use; (2) any contraceptive method; (3) dual use of a condom and either birth control pills; IUD or implant; or shot, patch, or birth control ring; and (4) primary contraceptive method. Primary contraceptive method options were (1) no method; (2) birth control pills; (3) condoms; (4) IUD or implant; (5) shot, patch, or birth control ring; (6) withdrawal or some other method; and (7) not sure. Logistic regression (prevalence ratios [PRs] and 95% confidence intervals [CIs]) and Chi-squares were used for testing. Students who received HIV education were more likely than students who did not to use a condom (PR:1.09;CI:1.01,1.18) and any contraceptive method (PR:1.08;CI:1.04,1.12); there was no significant association with dual use. Primary contraceptive method varied significantly by receipt of HIV education (p?<?.001). School-based HIV education may be important for promotion of adolescent condom and contraceptive use.

      5. HIV-related stigma by healthcare providers in the United States: A systematic reviewExternal
        Geter A, Herron AR, Sutton MY.
        AIDS Patient Care STDS. 2018 Oct;32(10):418-424.

        Reducing HIV-related stigma may enhance the quality of HIV prevention and care services and is a national prevention goal. The objective of this systematic review was to identify studies of HIV-related stigma among healthcare providers. For studies published between 2010 and 2017, we: (1) searched databases using our keywords, (2) excluded nonpeer reviewed studies, (3) limited the findings to the provider perspective and studies conducted in the United States, (4) extracted and summarized the data, and (5) conducted a contextual review to identify common themes. Of 619 studies retrieved, 6 were included, with 3 themes identified: (1) attitudes, beliefs, and behaviors (n = 6), (2) quality of patient care (n = 3), and (3) education and training (n = 2). Factors associated with HIV-related stigma varied by gender, race, provider category, and clinical setting. Providers with limited recent HIV-stigma training were more likely to exhibit stigmatizing behaviors toward patients. Developing provider-centered stigma-reduction interventions may help advance national HIV prevention and care goals.

      6. Repeated Chlamydia trachomatis infections are associated with lower bacterial loadsExternal
        Gupta K, Bakshi RK, Van Der Pol B, Daniel G, Brown L, Press CG, Gorwitz R, Papp J, Lee JY, Geisler WM.
        Epidemiol Infect. 2018 Oct 4:1-3.

        Chlamydia trachomatis (CT) infections remain highly prevalent. CT reinfection occurs frequently within months after treatment, likely contributing to sustaining the high CT infection prevalence. Sparse studies have suggested CT reinfection is associated with a lower organism load, but it is unclear whether CT load at the time of treatment influences CT reinfection risk. In this study, women presenting for treatment of a positive CT screening test were enrolled, treated and returned for 3- and 6-month follow-up visits. CT organism loads were quantified at each visit. We evaluated for an association of CT bacterial load at initial infection with reinfection risk and investigated factors influencing the CT load at baseline and follow-up in those with CT reinfection. We found no association of initial CT load with reinfection risk. We found a significant decrease in the median log10 CT load from baseline to follow-up in those with reinfection (5.6 CT/ml vs. 4.5 CT/ml; P = 0.015). Upon stratification of reinfected subjects based upon presence or absence of a history of CT infections prior to their infection at the baseline visit, we found a significant decline in the CT load from baseline to follow-up (5.7 CT/ml vs. 4.3 CT/ml; P = 0.021) exclusively in patients with a history of CT infections prior to our study. Our findings suggest repeated CT infections may lead to possible development of partial immunity against CT.

      7. Simple estimates for local prevalence of latent tuberculosis infection, United States, 2011-2015External
        Haddad MB, Raz KM, Lash TL, Hill AN, Kammerer JS, Winston CA, Castro KG, Gandhi NR, Navin TR.
        Emerg Infect Dis. 2018 Oct;24(10):1930-1933.

        We used tuberculosis genotyping results to derive estimates of prevalence of latent tuberculosis infection in the United States. We estimated <1% prevalence in 1,981 US counties, 1%-<3% in 785 counties, and >3% in 377 counties. This method for estimating prevalence could be applied in any jurisdiction with an established tuberculosis surveillance system.

      8. Severe respiratory illness outbreak associated with human coronavirus NL63 in a long-term care facilityExternal
        Hand J, Rose EB, Salinas A, Lu X, Sakthivel SK, Schneider E, Watson JT.
        Emerg Infect Dis. 2018 Oct;24(10):1964-1966.

        We describe an outbreak of severe respiratory illness associated with human coronavirus NL63 in a long-term care facility in Louisiana in November 2017. Six of 20 case-patients were hospitalized with pneumonia, and 3 of 20 died. Clinicians should consider human coronavirus NL63 for patients in similar settings with respiratory disease.

      9. Developing a model to predict unfavourable treatment outcomes in patients with tuberculosis and human immunodeficiency virus co-infection in Delhi, IndiaExternal
        Madan C, Chopra KK, Satyanarayana S, Surie D, Chadha V, Sachdeva KS, Khanna A, Deshmukh R, Dutta L, Namdeo A, Shukla A, Sagili K, Chauhan LS.
        PLoS One. 2018 ;13(10):e0204982.

        BACKGROUND: Tuberculosis (TB) patients with human immunodeficiency virus (HIV) co-infection have worse TB treatment outcomes compared to patients with TB alone. The distribution of unfavourable treatment outcomes differs by socio-demographic and clinical characteristics, allowing for early identification of patients at risk. OBJECTIVE: To develop a statistical model that can provide individual probabilities of unfavourable outcomes based on demographic and clinical characteristics of TB-HIV co-infected patients. METHODOLOGY: We used data from all TB patients with known HIV-positive test results (aged >/=15 years) registered for first-line anti-TB treatment (ATT) in 2015 under the Revised National TB Control Programme (RNTCP) in Delhi, India. We included variables on demographics and pre-treatment clinical characteristics routinely recorded and reported to RNTCP and the National AIDS Control Organization. Binomial logistic regression was used to develop a statistical model to estimate probabilities of unfavourable TB treatment outcomes (i.e., death, loss to follow-up, treatment failure, transfer out of program, and a switch to drug-resistant regimen). RESULTS: Of 55,260 TB patients registered for ATT in 2015 in Delhi, 928 (2%) had known HIV-positive test results. Of these, 816 (88%) had drug-sensitive TB and were >/=15 years. Among 816 TB-HIV patients included, 157 (19%) had unfavourable TB treatment outcomes. We developed a model for predicting unfavourable outcomes using age, sex, disease classification (pulmonary versus extra-pulmonary), TB treatment category (new or previously treated case), sputum smear grade, known HIV status at TB diagnosis, antiretroviral treatment at TB diagnosis, and CD4 cell count at ATT initiation. The chi-square p-value for model calibration assessed using the Hosmer-Lemeshow test was 0.15. The model discrimination, measured as the area under the receiver operator characteristic (ROC) curve, was 0.78. CONCLUSION: The model had good internal validity, but should be validated with an independent cohort of TB-HIV co-infected patients to assess its performance before clinical or programmatic use.

      10. BACKGROUND: HIV pre-exposure prophylaxis (PrEP) is efficacious, however many MSM (especially racial/ethnic minorities) are still unaware of and under-utilize it. METHODS: The 2014 Messages4Men Study focuses on black and Hispanic/Latino MSM in Chicago, Fort Lauderdale, and Kansas City (n=937). Brief (2-3 sentence) messages were tested: a PrEP message tailored for HIV-uninfected MSM (n=607) and a PrEP message tailored for HIV-infected MSM (n=330). After reading the message, participants reported believability and awareness, and intent to use PrEP and condoms. Analyses consisted of bivariate and multivariable approaches. RESULTS: Among HIV-uninfected MSM, black (vs. Hispanic/Latino) MSM indicated greater intentions to use PrEP (81% vs. 70% respectively, p<.05); 72% overall had similar intentions to use condoms after hearing a PrEP message. PrEP information was new (63%) and believable (80%), with no racial/ethnic differences (p>.05). In multivariable analysis, men who reported recent condomless anal sex were less likely to report the PrEP message enhanced their intent to use condoms in the future. DISCUSSION: Several years into the availability of PrEP, black and Hispanic/Latino MSM continue to be unaware of PrEP and its benefits, although information is largely believable once provided. The HIV prevention field should be prepared to incorporate new information about HIV prevention options into brief messages delivered through technology and social media.

      11. Reconsidering the number of women with HIV infection who give birth annually in the United StatesExternal
        Nesheim SR, FitzHarris LF, Lampe MA, Gray KM.
        Public Health Rep. 2018 Sep 28:33354918800466.

        OBJECTIVES: The annual number of women with HIV infection who delivered infants in the United States was estimated to be 8700 in 2006. An accurate, current estimate is important for guiding perinatal HIV prevention efforts. Our objective was to analyze whether the 2006 estimate was consistent with the number of infants with HIV infection observed in the United States and with other data on perinatal HIV transmission. METHODS: We compared the number of infants born with HIV in 2015 (n = 53) with data on interventions to prevent perinatal HIV transmission (eg, maternal HIV diagnosis before and during pregnancy and prenatal antiretroviral use). We also estimated the annual number of deliveries to women living with HIV by using the number of women of childbearing age living with HIV during 2008-2014 and the estimated birth rate among these women. Finally, we determined any changes in the annual number of infants born to women with HIV from 2007-2015, among 19 states that reported these data. RESULTS: The low number of infants born in the United States with HIV infection and the uptake of interventions to prevent perinatal HIV transmission were not consistent with the 2006 estimate (n = 8700), even with the best uptake of interventions to prevent perinatal HIV transmission. Given the birth rate among women with HIV (estimated at 7%) and the number of women aged 13-44 living with HIV during 2008-2014 (n = 111 273 in 2008, n = 96 363 in 2014), no more than about 5000 women with HIV would be giving birth. Among states consistently reporting the annual number of births to women with HIV, the number declined about 14% from 2008 to 2014. CONCLUSION: The current annual number of women with HIV infection delivering infants in the United States is about 5000, which is substantially lower than the 2006 estimate. More accurate estimates would require comprehensive reporting of perinatal HIV exposure.

      12. Using Chlamydia trachomatis anorectal specimens routinely tested for LGV (2008-2011) and samples of archived specimens tested for LGV (2012-2015), we observed increased LGV positivity among men-who-have-sex-with-men attending NYC Sexual Health Clinics. Using clinical data, we determined predictors of anorectal LGV that may guide clinical management.

      13. BACKGROUND: Transgender women and transgender men are disproportionately affected by HIV infection and may be vulnerable to other STDs, but the lack of surveillance data inclusive of gender identity hinders prevention and intervention strategies. METHODS: We analyzed data from 506 transgender women (1,045 total visits) and 120 transgender men (209 total visits) who attended 26 publicly funded clinics that provide STD services in six US cities during a 3.5-year observation period. We used clinical and laboratory data to examine the proportion of transgender women and transgender men who tested positive for urogenital and extragenital chlamydial or gonococcal infections and who self-reported or tested positive for HIV infection during the observation period. RESULTS: Of the transgender women tested, 13.1% tested positive for chlamydia and 12.6% tested positive for gonorrhea at one or more anatomic sites, and 14.2% were HIV-infected. Of transgender men tested, 7.7% and 10.5% tested positive for chlamydia and gonorrhea at one or more anatomic sites, and 8.3% were HIV-infected., Most transgender women (86.0% and 80.9%, respectively) and more than a quarter of transgender men (28.6% and 28.6%, respectively) with an extragenital chlamydial or gonococcal infection had a negative urogenital test at the same visit. CONCLUSIONS: Publicly funded clinics providing STD services are likely an important source of STD care for transgender persons. More data are needed to understand the most effective screening approaches for urogenital, rectal, and pharyngeal CT and GC infections in transgender populations.

      14. Factors contributing to congenital syphilis cases – New York City, 2010-2016External
        Slutsker JS, Hennessy RR, Schillinger JA.
        MMWR Morb Mortal Wkly Rep. 2018 Oct 5;67(39):1088-1093.

        Congenital syphilis occurs when syphilis is transmitted from a pregnant woman to her fetus; congenital syphilis can be prevented through screening and treatment during pregnancy. Transmission to the fetus can occur at any stage of maternal infection, but is more likely during primary and secondary syphilis, with rates of transmission up to 100% at these stages (1). Untreated syphilis during pregnancy can cause spontaneous abortion, stillbirth, and early infant death. During 2013-2017, national rates of congenital syphilis increased from 9.2 to 23.3 cases per 100,000 live births (2), coinciding with increasing rates of primary and secondary syphilis among women of reproductive age (3). In New York City (NYC), cases of primary and secondary syphilis among women aged 15-44 years increased 147% during 2015-2016. To evaluate measures to prevent congenital syphilis, the NYC Department of Health and Mental Hygiene (DOHMH) reviewed data for congenital syphilis cases reported during 2010-2016 and identified patient-, provider-, and systems-level factors that contributed to these cases. During this period, 578 syphilis cases among pregnant women aged 15-44 years were reported to DOHMH; a congenital syphilis case was averted or otherwise failed to occur in 510 (88.2%) of these pregnancies, and in 68, a case of congenital syphilis occurred (eight cases per 100,000 live births).* Among the 68 pregnant women associated with these congenital syphilis cases, 21 (30.9%) did not receive timely (>/=45 days before delivery) prenatal care. Among the 47 pregnant women who did access timely prenatal care, four (8.5%) did not receive an initial syphilis test until <45 days before delivery, and 22 (46.8%) acquired syphilis after an initial nonreactive syphilis test. These findings support recommendations that health care providers screen all pregnant women for syphilis at the first prenatal care visit and then rescreen women at risk in the early third trimester.

      15. Repeated false-positive HIV test results in a patient taking HIV pre-exposure prophylaxisExternal
        Stekler JD, Violette LR, Niemann L, McMahan VM, Katz DA, Baeten JM, Grant RM, Delaney KP.
        Open Forum Infect Dis. 2018 Sep;5(9):ofy197.

        Regular HIV testing is required to ensure the safety of HIV pre-exposure prophylaxis (PrEP). We describe and discuss a series of false-positive HIV test results from an individual receiving PrEP. The expansion of PrEP will likely result in greater numbers of false-positive test results that may pose challenges for interpretation.

      16. Distribution of hepatitis A antibodies in US blood donorsExternal
        Tejada-Strop A, Zafrullah M, Kamili S, Stramer SL, Purdy MA.
        Transfusion. 2018 Oct 4.

        BACKGROUND: Recently, there has been an increase in the number of hepatitis A outbreaks in the United States. Although the presence of hepatitis A virus (HAV) RNA in blood donors is known to be low, HAV antibody prevalence in this population is unknown. STUDY DESIGN AND METHODS: Samples from 5001 US blood donors collected primarily in the midwestern United States in 2015 were tested for the presence of HAV IgG antibodies using chemiluminescent microparticle immunoassays on the ARCHITECT platform (Abbott Laboratories). RESULTS: The overall prevalence of IgG anti-HAV was 60%. Only one specimen was IgM anti-HAV positive, for an incidence of 0.02%. IgG anti-HAV prevalence among donors aged 16 to 19 years was 67%, decreased to 54% among donors aged 40 to 49 years and increased to 70% among donors aged 80 to 93 years. No differences were seen by sex with overall IgG anti-HAV prevalence of 61% and 60% for males and females, respectively. Among the five states (Illinois, Indiana, Kansas, Kentucky, and Missouri) with the highest number of donors tested, IgG anti-HAV prevalence in Missouri (65%) was significantly higher (p <0.01) than that in Illinois (52%) or Kentucky (59%). No other significant differences between states were noted. CONCLUSION: This study demonstrates the overall high rates of IgG anti-HAV in US blood donors, with the low associated risk of HAV transfusion transmission likely the result of low incidence and effective vaccination.

      17. HIV care and viral load suppression after sexual health clinic visits by out-of-care HIV-positive personsExternal
        Tymejczyk O, Jamison K, Pathela P, Braunstein S, Schillinger JA, Nash D.
        AIDS Patient Care STDS. 2018 Oct;32(10):390-398.

        Outcomes among people living with HIV (PLWH) in New York City (NYC) remain suboptimal. To assess the potential role of the city’s sexual health clinics (SHCs) in improving HIV outcomes and reducing HIV transmission, we examined HIV care status and its correlates among HIV-positive SHC patients in NYC. Clinic electronic medical records were merged with longitudinal NYC HIV surveillance data to identify HIV-positive patients and derive their retrospective and prospective HIV care status. Evidence of HIV care and viral load suppression (VLS) after clinic visit were considered outcomes. Logistic regression models were used to assess their correlates. A third of the 1045 PLWH who visited NYC SHCs in 2012 were out of HIV care (OOC) in the 12 months preceding the clinic visit, and were less likely than those previously in HIV care (IC) to have subsequent evidence of HIV care (42% vs. 72%) or VLS in the 12 months after the visit (39% vs. 76%). VLS was particularly low among patients diagnosed with >/=2 sexually transmitted infections (46%). The odds of VLS were lowest among those OOC before the clinic visit [versus those IC, adjusted odds ratio (aOR): 0.21, 95% confidence interval (CI): 0.16-0.29], non-Hispanic blacks (versus non-Hispanic whites, aOR: 0.58, 95% CI: 0.37-0.90), and residents of high-poverty neighborhoods (>30% vs. <10%, aOR: 0.51, 95% CI: 0.29-0.89). Our findings suggest that SHCs could serve as an intervention point to (re-)link PLWH to HIV care. Real-time provider alerts about patients’ OOC status could help achieve that goal.

      18. Distribution of HIV self-tests by HIV-positive men who have sex with men to social and sexual contactsExternal
        Wesolowski L, Chavez P, Sullivan P, Freeman A, Sharma A, Mustanski B, McNaghten AD, MacGowan R.
        AIDS Behav. 2018 Sep 27.

        HIV-positive men who have sex with men (MSM) were recruited on www.Facebook.com and www.Poz.com to give HIV self-tests to their contacts. Study participants completed a baseline survey, were given two self-tests, and completed a survey 2 months later. Of 133 eligible men, 40 (30%) completed both surveys. Most participants were 30-54 years old and non-Hispanic white. Some had a detectable viral load (n = 4), had condomless anal sex with male partners of negative or unknown status (n = 17), and had met anal sex partners at gay dating websites (n = 23). Of 80 self-tests given to participants, 59 (74%) were distributed, primarily to non-Hispanic white MSM, 30-54 years old who were friends. Participants reported results from 31 distributed tests; 2 sex partners of participants had positive results. Participants indicated these two persons were unaware of their infections. Expanding recruitment websites might reach non-white MSM. Unrecognized infections were identified through online recruitment and self-test distribution via HIV-positive persons.

    • Disaster Control and Emergency Services
      1. Emergency preparedness training for hospital nursing staff, New York City, 2012-2016External
        Jacobs-Wingo JL, Schlegelmilch J, Berliner M, Airall-Simon G, Lang W.
        J Nurs Scholarsh. 2018 .

        Purpose: Many nurses are trained inadequately in emergency preparedness (EP), preventing them from effectively executing response roles during disasters, such as chemical, biological, radiological, nuclear, and explosive (CBRNE) events. Nurses also indicate lacking confidence in their abilities to perform EP activities. The purpose of this article is to describe the phased development of, and delivery strategies for, a CBRNE curriculum to enhance EP among nursing professionals. The New York City (NYC) Department of Health and Mental Hygiene (DOHMH) and the National Center for Disaster Preparedness at Columbia University’s Earth Institute led the initiative. Methods: Curriculum development included four phases. In Phases I and II, nursing staff at 20 participating NYC hospitals conducted 7,177 surveys and participated in 20 focus groups to identify training gaps in EP. In Phase III, investigators developed and later refined the CBRNE curriculum based on gaps identified. In Phase IV, 22 nurse educators (representing 7 of the original 20 participating hospitals) completed train-the-trainer sessions. Of these nurse educators, three were evaluated on their ability to train other nurses using the curriculum, which investigators finalized. Findings: The CBRNE curriculum included six modules, a just-in-time training, and an online annual refresher course that addressed EP gaps identified in surveys and focus groups. Among the 11 nurses who were trained by three nurse educators during a pilot training, participant knowledge of CBRNE events and response roles increased from an average of 54% (range 45%-75%) on the pre-test to 89% (range 80%-90%) on the posttest. Conclusions: By participating in nursing CBRNE training, nurses increased their knowledge of and preparedness to respond to disasters. The train-the-trainer curriculum is easily adaptable to meet the needs of other healthcare settings. Clinical Relevance: The CBRNE curriculum can be used to train nurses to better prepare for and more effectively respond to disasters. Published 2018. This article is a U.S. Government work and is in the public domain in the USA.

    • Environmental Health
      1. Prenatal exposure to perfluoroalkyl substances: Infant birth weight and early life growthExternal
        Shoaff J, Papandonatos GD, Calafat AM, Chen A, Lanphear BP, Ehrlich S, Kelsey KT, Braun JM.
        Environ Epidemiol. 2018 Jun;2(2).

        Background: Prenatal perfluoroalkyl substance (PFAS) exposure has been associated with reduced birth weight and excess child adiposity, but the relationship between PFAS and early life growth is unknown. Objective: To determine if prenatal PFAS exposure was associated with birth weight, body composition and growth until 2 years of age. Methods: In a prospective cohort of women and their children from Cincinnati, OH, we quantified perfluorooctanoic acid (PFOA), perfluorooctane sulfonic acid (PFOS), perfluorononanoic acid (PFNA), and perfluorohexane sulfonic acid (PFHxS) in pregnant women’s serum. We used linear regression to estimate associations of PFAS with birth weight z-scores (n=345) and linear mixed models to estimate associations with repeated weight and length/height measurements (n=334) at ages 4 weeks and 1 and 2 years, after adjusting for sociodemographic, perinatal, nutritional, and environmental factors. Results: We found non-significant inverse associations between PFAS and infant birth weight. For example, each log2 increase in PFOA was associated with a 0.03 standard deviation reduction in birth weight z-score (95% CI:-0.17, 0.10). Compared to associations with birth weight, we observed stronger associations between PFAS and child anthropometry from 4 weeks to 2 years. For instance, each log2 increase in PFOA was associated with a 0.12 standard deviation decrease in BMI z-score (95% CI: -0.25, 0.01). We did not observe any differences in growth rate associated with PFAS. Conclusion: We observed inverse associations between prenatal serum PFAS concentrations and anthropometry until age 2 years. Prenatal serum PFAS concentrations were not associated with growth rate in the first 2 years of life.

    • Food Safety
      1. Notes from the Field: Multiple Cyclosporiasis Outbreaks – United States, 2018External
        Casillas SM, Bennett C, Straily A.
        MMWR Morb Mortal Wkly Rep. 2018 Oct 5;67(39):1101-1102.

        [No abstract]

      2. Outbreak of Salmonella Chailey infections linked to precut coconut pieces – United States and Canada, 2017External
        Luna S, Taylor M, Galanis E, Asplin R, Huffman J, Wagner D, Hoang L, Paccagnella A, Shelton S, Ladd-Wilson S, Seelman S, Whitney B, Elliot E, Atkinson R, Marshall K, Basler C.
        MMWR Morb Mortal Wkly Rep. 2018 Oct 5;67(39):1098-1100.

        Foodborne salmonellosis causes an estimated 1 million illnesses and 400 deaths annually in the United States (1). In recent years, salmonellosis outbreaks have been caused by foods not typically associated with Salmonella. On May 2, 2017, PulseNet, CDC’s national molecular subtyping network for foodborne disease surveillance, identified a cluster of 14 Salmonella Chailey isolates with a rare pulsed-field gel electrophoresis (PFGE) pattern. On May 29, Canadian health officials informed CDC that they were also investigating a cluster of five Salmonella Chailey infections in British Columbia with the same PFGE pattern. Nineteen cases were identified and investigated by CDC, U.S. state health departments, the Public Health Agency of Canada, and the British Columbia Centre for Disease Control. Isolates from all cases were highly related by whole genome sequencing (WGS). Illness onset dates ranged from March 10 to May 7, 2017. Initial interviews revealed that infected persons consumed various fresh foods and shopped at grocery chain A; focused questionnaires identified precut coconut pieces from grocery chain A as a common vehicle. The Canadian Food Inspection Agency (CFIA) and the U.S. Food and Drug Administration (FDA) conducted a traceback investigation that implicated a single lot of frozen, precut coconut as the outbreak source. Grocery chain A voluntarily removed precut coconut pieces from their stores. This action likely limited the size and scope of this outbreak.

    • Health Disparities
      1. OBJECTIVE: To assess county-level socioeconomic disparities in medical service usage for infections among Medicare beneficiaries with diabetes (MBWDs) who had fee-for-service health insurance claims during 2012. DESIGN: We used Medicare claims data to calculate percentage of MBWDs with infections. SETTING: Medicare beneficiaries. PARTICIPANTS: We estimated the percentage of MBWDs who used medical services for each of 3 groups of infections by sex and quintiles of the prevalence of social factors in the person’s county of residence: anatomic site-specific infections; pathogen-specific infections; and HHST infections (human immunodeficiency virus/acquired immunodeficiency syndrome, viral hepatitis, sexually transmitted diseases, and tuberculosis). MAIN OUTCOME MEASURES: Using quintiles of county-specific socioeconomic determinants, we calculated absolute and relative disparities in each group of infections for male and female MBWDs. We also used regression-based summary measures to estimate the overall average absolute and relative disparities for each infection group. RESULTS: Of the 4.5 million male MBWDs, 15.8%, 25.3%, and 2.7% had 1 or more site-specific, pathogen-specific, and HHST infections, respectively. Results were similar for females (n = 5.2 million). The percentage of MBWDs with 1 or more infections in each group increased as social disadvantage in the MBWDs’ county of residence increased. Absolute and relative county-level socioeconomic disparities in receipt of medical services for 1 or more infections (site- or pathogen-specific) were 12.9 or less percentage points and 65.5% or less, respectively. For HHST infections, percentage of MBWDs having 1 or more HHST infections for persons residing in the highest quintile (Q5) was 3- to 4-fold higher (P < .001) than persons residing in the lowest quintile (Q1). CONCLUSIONS: Infection burden among MBWDs is generally associated with county-level contextual socioeconomic disadvantage, and the extent of health disparities varies by infection category, socioeconomic factor, and quintiles of socioeconomic disadvantage. The findings imply ongoing need for efforts to identify effective interventions for reducing county-level social disparities in infections among patients with diabetes.

      2. Racism, African American women, and their sexual and reproductive health: A review of historical and contemporary evidence and implications for health equityExternal
        Prather C, Fuller TR, Jeffries WL, Marshall KJ, Howell AV, Belyue-Umole A, King W.
        Health Equity. 2018 ;2(1):249-259.

        Background: The sexual and reproductive health of African American women has been compromised due to multiple experiences of racism, including discriminatory healthcare practices from slavery through the post-Civil Rights era. However, studies rarely consider how the historical underpinnings of racism negatively influence the present-day health outcomes of African American women. Although some improvements to ensure equitable healthcare have been made, these historical influences provide an unexplored context for illuminating present-day epidemiology of sexual and reproductive health disparities among African American women. Methods: To account for the unique healthcare experiences influenced by racism, including healthcare provision, we searched online databases for peer-reviewed sources and books published in English only. We explored the link between historical and current experiences of racism and sexual and reproductive health outcomes. Results: The legacy of medical experimentation and inadequate healthcare coupled with social determinants has exacerbated African American women’s complex relationship with healthcare systems. The social determinants of health associated with institutionalized and interpersonal racism, including poverty, unemployment, and residential segregation, may make African American women more vulnerable to disparate sexual and reproductive health outcomes. Conclusions: The development of innovative models and strategies to improve the health of African American women may be informed by an understanding of the historical and enduring legacy of racism in the United States. Addressing sexual and reproductive health through a historical lens and ensuring the implementation of culturally appropriate programs, research, and treatment efforts will likely move public health toward achieving health equity. Furthermore, it is necessary to develop interventions that address the intersection of the social determinants of health that contribute to sexual and reproductive health inequities.

      3. We examined changes in federal sexually transmitted disease funding allocations to areas with high racial/ethnic disparities in sexually transmitted diseases after the implementation of a funding formula in 2014. The funding formula increased prevention funding allocations to areas with high relative racial/ethnic disparities. Results were mixed for areas with high absolute disparities.

    • Health Economics
      1. Medical expenditures associated with diabetes among adult Medicaid enrollees in eight statesExternal
        Ng BP, Shrestha SS, Lanza A, Smith B, Zhang P.
        Prev Chronic Dis. 2018 Sep 27;15:E116.

        INTRODUCTION: Little information is available on state-specific financial burdens of diabetes in the Medicaid population, yet such information is essential for state Medicaid programs to plan diabetes care and evaluate the benefits of diabetes prevention. We estimated medical expenditures associated with diabetes among adult Medicaid enrollees in 8 states. METHODS: We analyzed the latest available 2012 CMS Medicaid claims data for 1,193,811 adult enrollees aged 19-64 years in 8 states: Alabama, California, Connecticut, Florida, Illinois, Iowa, New York, and Oklahoma. For each state, we stratified the study population by Medicaid eligibility criteria: disability and nondisability. For each group, we estimated per capita annual medical expenditures on outpatient care, inpatient care, and prescription drugs by using a 2-part model, adjusted for age, sex, race/ethnicity, and comorbidities. We calculated the expenditures associated with diabetes as the difference in predicted expenditures for enrollees with and without diabetes. Analyses were done in 2017. RESULTS: For disability-based enrollees, the estimated total per capita annual diabetes expenditures ranged from $6,183 in Alabama to $15,319 in New York (all P < .001). For nondisability-based enrollees, the corresponding estimates ranged from $4,985 in Alabama to $15,366 in New York (all P < .001). The proportion of individual components varied by state and eligibility criteria. CONCLUSION: Medical expenditures associated with diabetes among adults on Medicaid were substantial and varied across studied states. Our estimates can be used by the 8 state Medicaid programs to prepare health care resources needed for diabetes care and assess the financial benefits of diabetes prevention programs.

      2. Prevalence of out-of-pocket payments for mammography screening among recently screened womenExternal
        Sabatino SA, Thompson TD, Miller JW, Breen N, White MC, Breslau E, Shoemaker ML.
        J Womens Health (Larchmt). 2018 Sep 28.

        BACKGROUND: Because cost may be a barrier to receiving mammography screening, cost sharing for “in-network” screening mammograms was eliminated in many insurance plans with implementation of the Affordable Care Act. We examined prevalence of out-of-pocket payments for screening mammography after elimination in many plans. MATERIALS AND METHODS: Using 2015 National Health Interview Survey data, we examined whether women aged 50-74 years who had screening mammography within the previous year (n = 3,278) reported paying any cost for mammograms. Logistic regression models stratified by age (50-64 and 65-74 years) examined out-of-pocket payment by demographics and insurance (ages 50-64 years: private, Medicaid, other, and uninsured; ages 65-74 years: private +/- Medicare, Medicare+Medicaid, Medicare Advantage, Medicare only, and other). RESULTS: Of women aged 50-64 years, 23.5% reported payment, including 39.1% of uninsured women. Compared with that of privately insured women, payment was less likely for women with Medicaid (adjusted OR 0.17 [95% CI 0.07-0.41]) or other insurance (0.49 [0.25-0.96]) and more likely for uninsured women (1.99 [0.99-4.02]) (p < 0.001 across groups). For women aged 65-74 years, 11.9% reported payment, including 22.5% of Medicare-only beneficiaries. Compared with private +/- Medicare beneficiaries, payment was less likely for Medicare+Medicaid beneficiaries (adjusted OR 0.21 [95% CI 0.06-0.73]) and more likely for Medicare-only beneficiaries (1.83 [1.01-3.32]) (p = 0.005 across groups). CONCLUSIONS: Although most women reported no payment for their most recent screening mammogram in 2015, some payment was reported by >20% of women aged 50-64 years or aged 65-74 years with Medicare only, and by almost 40% of uninsured women aged 50-64 years. Efforts are needed to understand why many women in some groups report paying out of pocket for mammograms and whether this impacts screening use.

      3. Provider payments and the receipt of human papillomavirus vaccine among privately insured adolescentsExternal
        Tsai Y, Lindley MC, Zhou F, Stokley S.
        Health Aff (Millwood). 2018 Oct;37(10):1587-1595.

        Financial concerns such as high vaccine purchase costs and inadequate insurance reimbursement are cited as a key barrier to human papillomavirus (HPV) vaccination of adolescents who are covered by private health insurance. Statistical evidence on the relationship between payments to providers for HPV vaccination and HPV vaccine uptake is limited. This study used data for 2008-14 from the MarketScan Commercial Claims and Encounters database and included adolescents ages 11-17 who had been continuously enrolled in the same noncapitated private insurance plan. Our estimates showed that a $1 increase in median provider payments in a state was associated with a 0.48-percentage-point increase in the probability of initiating the HPV vaccine series and a 0.25-percentage-point increase in the probability of receiving two or more doses. These numbers translated to an average increase of 49,435 adolescents initiating the series and 25,314 adolescents receiving two or more doses. The association between provider payments and HPV vaccine uptake was stronger among adolescents ages 11-12 than among older adolescents, and among adolescents who lived in a Metropolitan Statistical Area than those who did not.

    • Healthcare Associated Infections
      1. Candida auris in healthcare facilities, New York, USA, 2013-2017External
        Adams E, Quinn M, Tsay S, Poirot E, Chaturvedi S, Southwick K, Greenko J, Fernandez R, Kallen A, Vallabhaneni S, Haley V, Hutton B, Blog D, Lutterloh E, Zucker H.
        Emerg Infect Dis. 2018 Oct;24(10):1816-1824.

        Candida auris is an emerging yeast that causes healthcare-associated infections. It can be misidentified by laboratories and often is resistant to antifungal medications. We describe an outbreak of C. auris infections in healthcare facilities in New York City, New York, USA. The investigation included laboratory surveillance, record reviews, site visits, contact tracing with cultures, and environmental sampling. We identified 51 clinical case-patients and 61 screening case-patients. Epidemiologic links indicated a large, interconnected web of affected healthcare facilities throughout New York City. Of the 51 clinical case-patients, 23 (45%) died within 90 days and isolates were resistant to fluconazole for 50 (98%). Of screening cultures performed for 572 persons (1,136 total cultures), results were C. auris positive for 61 (11%) persons. Environmental cultures were positive for samples from 15 of 20 facilities. Colonization was frequently identified during contact investigations; environmental contamination was also common.

      2. Clostridioides difficile InfectionExternal
        Guh AY, Kutty PK.
        Ann Intern Med. 2018 Oct 2;169(7):Itc49-itc64.

        Clostridioides difficile (formerly Clostridium difficile) infection is the most frequently identified health care-associated infection in the United States. C difficile has also emerged as a cause of community-associated diarrhea, resulting in increased incidence of community-associated infection. Clinical illness ranges in severity from mild diarrhea to fulminant colitis and death. Appropriate management of infection requires understanding of the various diagnostic assays and therapeutic options as well as relevant measures to infection prevention. This article provides updated recommendations regarding the prevention, diagnosis, and treatment of incident and recurrent C difficile infection.

    • Immunity and Immunization
      1. Influenza vaccination coverage among English-speaking Asian AmericansExternal
        Srivastav A, O’Halloran A, Lu PJ, Williams WW.
        Am J Prev Med. 2018 Sep 19.

        INTRODUCTION: English-speaking non-Hispanic Asians (Asians) in the U.S. include populations with multiple geographic origins and ethnicities (e.g., Asian Indian, Chinese, Filipino, Japanese, Korean, and Vietnamese). Health behaviors and outcomes can differ widely among Asian ethnicities, and highlight the importance of subgroup analysis. Aggregating Asians may mask differences in influenza vaccination across various ethnicities. METHODS: Combined data from 2013 to 2015 Behavioral Risk Factor Surveillance System, a population-based, telephone survey of the non-institutionalized, U.S. population aged >/=18years, were analyzed in 2017 to assess influenza vaccination among Asians. Weighted proportions were calculated. Multivariable logistic regression was used to determine independent associations between sociodemographic factors and receipt of influenza vaccination. RESULTS: Influenza vaccination varied widely among Asian ethnicities, both nationally and by state. Overall, 42.1% of Asians reported having received an influenza vaccine, similar to vaccination among whites (42.4%). Coverage ranged from 36.1% among Koreans to 50.9% among Japanese. Factors independently associated with influenza vaccination among some or all Asian ethnicities included age (>/=50 years), female, never married, high school or higher education, annual household income >/=$75,000, possession of medical insurance and personal healthcare provider, routine checkup in the previous year, and presence of certain chronic conditions. CONCLUSIONS: Though Asians and whites had similar overall influenza vaccination coverage, differences existed between Asian ethnicities, both nationally and by state. This information may help community-based, state-level, and national-level public health agencies to support targeted approaches for outreach to these populations, such as improving cultural and linguistic access to care, to improve influenza vaccination.

      2. A DS-1 like G9P[6] human strain CDC-6 as a new rotavirus vaccine candidateExternal
        Wang Y, Resch T, Esona MD, Moon SS, Jiang B.
        Vaccine. 2018 Sep 24.

        Human rotavirus vaccine Rotarix(R) (G1P[8]) has shown broad cross protection against homotypic and heterotypic Wa-like human rotavirus strains among children worldwide. This vaccine, however, appears to induce slightly less or non-consistent protection against DS-1 like rotavirus P[4] strains in some settings. In addition, children who are secretor or Lewis-negative and are vaccinated with Rotarix(R) often experience breakthrough infection with P[6] strains. By contrast, P[6] strains infect all children, irrespective of their secretor or Lewis status. In the present study, we report successful adaptation of a DS-1 like human rotavirus G9P[6] strain (CDC-6) to high growth in Vero cells and identify sequence changes that may be critical for enhanced growth in vitro and attenuation in vivo. This human G9P[6] strain could serve as a promising new and potential low-cost vaccine candidate for global use, particularly in targeted population with secretor or Lewis-negative status and high prevalent DS-1 like P[6] strains.

    • Injury and Violence
      1. The Eyberg Child Behavior Inventory (ECBI) has previously been shown to be a psychometrically sound instrument used to assess disruptive behaviors in children in the United States and in other cultures/countries but not in Taiwan. The purpose of this study was to examine the factor structure and to establish the discriminative validity of the ECBI with two groups of Taiwanese children: 70 clinic-referred children with clinically elevated externalizing behavior problems and 70 community-based matched comparison children. Exploratory factor analyses resulted in a six-factor model for the clinic-referred sample and a five-factStrengths and Difficultieor model for the matched comparison sample, indicating that the ECBI is not unidimensional. Adequate convergent and divergent validity also were established between the ECBI Intensity and Problem Scales and another measure of child externalizing (for assessing convergent validity) and internalizing (for determining divergent validity) behavior. The results of the present study suggest that the ECBI is a valid measure of assessing externalizing behavior problems in Taiwanese children. Future research may seek to refine the factor structure of the ECBI in a Taiwanese sample. Future studies are also needed to examine other psychometrics of the ECBI, replicate this study with a larger sample, and establish its normative data in Taiwan.

      2. Prevalence of parent-reported traumatic brain injury in children and associated health conditionsExternal
        Haarbauer-Krupa J, Lee AH, Bitsko RH, Zhang X, Kresnow-Sedacca MJ.
        JAMA Pediatr. 2018 Sep 24.

        Importance: Traumatic brain injury (TBI) in children results in a high number of emergency department visits and risk for long-term adverse effects. Objectives: To estimate lifetime prevalence of TBI in a nationally representative sample of US children and describe the association between TBI and other childhood health conditions. Design, Setting, and Participants: Data were analyzed from the 2011-2012 National Survey of Children’s Health, a cross-sectional telephone survey of US households with a response rate of 23%. Traumatic brain injury prevalence estimates were stratified by sociodemographic characteristics. The likelihood of reporting specific health conditions was compared between children with and without TBI. Age-adjusted prevalence estimates were computed for each state. Associations between TBI prevalence, insurance type, and parent rating of insurance adequacy were examined. Data analysis was conducted from February 1, 2016, through November 1, 2017. Main Outcomes and Measures: Lifetime estimate of TBI in children, associated childhood health conditions, and parent report of health insurance type and adequacy. Results: The lifetime estimate of parent-reported TBI among children was 2.5% (95% CI, 2.3%-2.7%), representing over 1.8 million children nationally. Children with a lifetime history of TBI were more likely to have a variety of health conditions compared with those without a TBI history. Those with the highest prevalence included learning disorders (21.4%; 95% CI, 18.1%-25.2%); attention-deficit/hyperactivity disorder (20.5%; 95% CI, 17.4%-24.0%); speech/language problems (18.6%; 95% CI, 15.8%-21.7%); developmental delay (15.3%; 95% CI, 12.9%-18.1%); bone, joint, or muscle problems (14.2%; 95% CI, 11.6%-17.2%); and anxiety problems (13.2%; 95% CI, 11.0%-16.0%). States with a higher prevalence of childhood TBI were more likely to have a higher proportion of children with private health insurance and higher parent report of adequate insurance. Examples of states with higher prevalence of TBI and higher proportion of private insurance included Maine, Vermont, Pennsylvania, Washington, Montana, Wyoming North Dakota, South Dakota, and Colorado. Conclusions and Relevance: A large number of US children have experienced a TBI during childhood. Higher TBI prevalence in states with greater levels of private insurance and insurance adequacy may suggest an underrecognition of TBI among children with less access to care. For more comprehensive monitoring, health care professionals should be aware of the increased risk of associated health conditions among children with TBI.

    • Laboratory Sciences
      1. Identity and validity of conserved B cell epitopes of filovirus glycoprotein: towards rapid diagnostic testing for Ebola and possibly Marburg virus diseaseExternal
        Babirye P, Musubika C, Kirimunda S, Downing R, Lutwama JJ, Mbidde EK, Weyer J, Paweska JT, Joloba ML, Wayengera M.
        BMC Infect Dis. 2018 Oct 3;18(1):498.

        BACKGROUND: Ebolavirus and Marburgvirus are genera of the virus family Filoviridae. Filoviruses cause rare but fatal viral hemorrhagic fevers (VHFs) in remote villages of equatorial Africa with potential for regional and international spread. Point-of-care (POC) rapid diagnostic tests (RDTs) are critical for early epidemic detection, reponse and control. There are 2 RDTs for Zaire ebolavirus (EBOV), but not other Ebolavirus spp. or Marburg marburgvirus (MARV). We validate 3 conserved B cell epitopes of filovirus glycoprotein (GP) using ebola virus diseases (EVD) survivor samples, towards devising pan-filovirus RDTs. METHODS: In-silico Immuno-informatics:- (a) multiple and basic local alignments of amino-acid sequences of filovirus (4 Ebolavirus spp. & MARV) Gp1, 2 and epitope prediction and conservation analyses within context of ClusterW, BLAST-P and the immune epitope database analysis resource (IEDB-AR); alongside (b) in-vitro enzyme immuno-assays (EIAs) for SUDV Gp1, 2 antigen and host-specific antibodies (IgM and IgG) among 94 gamma irradiated EVD survivor serum and 9 negative controls. RESULTS: Linear B cell epitopes were present across the entire length of all Gp1, 2, most lying in the region between amino acids positioned 350 and 500. Three seperate epitopes 97/80_GAFFLYDRLAST, 39_YEAGEWAENCY and 500_CGLRQLANETTQALQLFLRATTELR (designated UG-Filo-Peptide- 1, 2 and 3 respectively) were conserved within all studied filovirus species Gp1, 2. Gp1, 2 host specific IgM levels were comparably low (av. ODs < 0.04 [95% CI: 0.02837 to 0.04033]) among the 9 negative controls and 57 survivor samples analyzed. Host specific IgG levels, on the other hand, were elevated (av. ODs > 1.7525 [95% CI: 0.3010 to 3.1352]) among the 92 survivor samples relative to the 9 negative controls (av. ODs < 0.2.321 [95% CI: -0.7596 to 0.5372]). Filovirus Gp1, 2 antigen was not detected [av. ODs < 0.20] within EVD survivor serum relative to recombinant protein positive controls [av. ODs = 0.50]. CONCLUSIONS: These conserved B cell epitopes of filovirus Gp1, 2 and their derivative antibodies are promising for research and development of RDTs for EVD, with potential for extension to detect MVD.

      2. Pneumococcal and legionella urinary antigen tests in community-acquired pneumonia: Prospective evaluation of indications for testingExternal
        Bellew S, Grijalva CG, Williams DJ, Anderson EJ, Wunderink RG, Zhu Y, Waterer GW, Bramley AM, Jain S, Edwards KM, Self WH.
        Clin Infect Dis. 2018 Sep 28.

        Background: Adult community-acquired pneumonia (CAP) guidelines from the Infectious Diseases Society of America (IDSA) and American Thoracic Society (ATS) include indications for urinary antigen tests (UATs) for Streptococcus pneumoniae (SP) and Legionella pneumophila (LP). These recommendations were based on expert opinion and have not been rigorously evaluated. Methods: We used data from a multicenter prospective surveillance study of adults hospitalized with CAP to evaluate the sensitivity and specificity of the IDSA/ATS UAT indications for identifying patients who test positive. SP and LP UATs were completed on all included patients. Separate analyses were completed for SP and LP using two-by-two contingency tables comparing the IDSA/ATS indications (UAT recommended vs not recommended) and UAT results (positive vs negative). Additionally, logistic regression was used to evaluate the association of each individual criterion in the IDSA/ATS indications with positive UAT results. Results: Among 1,941 patients, UATs were positive for SP in 81 (4.2%) and LP in 32 (1.6%). IDSA/ATS indications had 61% (95% CI: 49%-71%) sensitivity and 39% (95% CI: 37%-41%) specificity for SP, and 63% (95% CI: 44%-79%) sensitivity and 35% (95% CI: 33%-37%) specificity for LP. No clinical characteristics were strongly associated with positive SP UATs, while features associated with positive LP UATs were hyponatremia, fever, diarrhea, and recent travel. Conclusions: Recommended indications for SP and LP urinary antigen testing in the IDSA/ATS CAP guidelines have poor sensitivity and specificity for identifying patients with positive tests; future CAP guidelines should consider other strategies for determining which patients should undergo urinary antigen testing.

      3. Field Epidemiology and Laboratory Training Program, where is the L-track?External
        Gatei W, Galgalo T, Abade A, Henderson A, Rayfield M, McAlister D, Montgomery JM, Peruski LF, Albetkova AA.
        Front Public Health. 2018 ;6:264.

        Background: Modifications of the Field Epidemiology Training Program (FETP) curricula to include a laboratory track (L-Track), to become Field Epidemiology and Laboratory Training Program (FELTP), began in 2004 in Kenya. The L-Track offered candidates training on laboratory competencies in management, policy, quality systems, and diagnostic methods as well as epidemiology, disease surveillance and outbreak response. Since then several FELTPs have discontinued the L-Track and instead offer all candidates, epidemiologists and laboratorians, a single FETP curriculum. Reasons for these changes are reported here. Methods: A questionnaire was sent to directors of 13 FELTP programs collecting information on the status of the programs, reasons for any changes, basic entry qualifications, source institutions and where residents were post enrollment or after graduation. Data from previous CDC internal assessments on FELTP L-Track was also reviewed. Results: Out of the 13 FELTPs included, directors from 10 FELTPs sent back information on their specific programs. The FELTPs in Kenya, Mozambique, Cameroon and Kazakhstan and Mali have discontinued a separate L-Track while those in Ghana, Georgia, Nigeria, Rwanda, and Tanzania continue to offer the separate L-Track. Reasons for discontinuation included lack of standardized curriculum, unclear strategies of the separate L-Track, and funding constraints. Two countries Kenya and Tanzania reported on the career progression of their graduates. Results show 84% (Kenya) and 51% (Tanzania) of candidates in the FELTP, L-Track were recruited from national/regional medical health laboratories. However post-graduation, 56% (Kenya) and 43% (Tanzania) were working as epidemiologists, program managers, program coordinators, or regulatory/inspection boards. Professional upward mobility was high; 87% (Kenya) and 73% (Tanzania) residents, reported promotions either in the same or in new institutions. Conclusions: The FELTP L-Track residents continue to offer critical contributions to public health workforce development with high upward mobility. While this may be a reflection of professional versatility and demand of the FELTP graduates, the move from core laboratory services underscores the challenges in filling and retaining qualified staff within the laboratory systems. Results suggest different strategies are needed to strengthen laboratory management and leadership programs with a clear focus on laboratory systems and laboratory networks to meet current and future clinical and public health laboratory workforce demands.

      4. Longevity of adenovirus vector immunity in mice and its implications for vaccine efficacyExternal
        Sayedahmed EE, Kumari R, Shukla S, Hassan AO, Mohammed SI, York IA, Gangappa S, Sambhara S, Mittal SK.
        Vaccine. 2018 Sep 25.

        There is a high incidence of adenovirus (AdV) infection in humans due to the presence of more than 60 types of human adenoviruses (HAdVs). The majority of individuals are exposed to one or more HAdV types early in their lives, leading to the development of AdV type-specific neutralizing antibodies. Similarly, immunization or gene therapy with AdV vectors leads to immune responses to the AdV vector. This ‘vector immunity’ is a concern for AdV vector-based applications for vaccines or gene therapy, especially when the repeated administration of a vector is required. The objective of this investigation was to establish whether AdV neutralizing antibody titers decline sufficiently in a year to permit annual vaccination with the same AdV vector. Naive or human adenoviral vector group C, type 5 (HAdV-C5)-primed mice were mock-inoculated (with PBS) or inoculated i.m. with 10(8)PFU of either HAd-GFP [HAdV-C5 vector expressing the green fluorescent protein (GFP)] to mimic the conditions for the first inoculation with an AdV vector-based vaccine. At 1, 3, 6, and 10months post-HAd-GFP inoculation, naive- or HAdV-primed animals were vaccinated i.m. with 10(8)PFU of HAd-H5HA [HAdV-C5 vector expressing hemagglutinin (HA) of H5N1 influenza virus]. There was a significant continual decrease in vector immunity titers with time, thereby leading to significant continual increases in the levels of HA-specific humoral and cell-mediated immune responses. In addition, significant improvement in protection efficacy against challenge with an antigenically heterologous H5N1 virus was observed in HAdV-primed animals at 6months and onwards. These results indicate that the annual immunization with the same AdV vector may be effective due to a significant decline in vector immunity.

      5. Iron catalysis of lipid peroxidation in ferroptosis: Regulated enzymatic or random free radical reaction?External
        Stoyanovsky DA, Tyurina YY, Shrivastava I, Bahar I, Tyurin VA, Protchenko O, Jadhav S, Bolevich SB, Kozlov AV, Vladimirov YA, Shvedova AA, Philpott CC, Bayir H, Kagan VE.
        Free Radic Biol Med. 2018 Sep 12.

        Duality of iron as an essential cofactor of many enzymatic metabolic processes and as a catalyst of poorly controlled redox-cycling reactions defines its possible biological beneficial and hazardous role in the body. In this review, we discuss these two “faces” of iron in a newly conceptualized program of regulated cell death, ferroptosis. Ferroptosis is a genetically programmed iron-dependent form of regulated cell death driven by enhanced lipid peroxidation and insufficient capacity of thiol-dependent mechanisms (glutathione peroxidase 4, GPX4) to eliminate hydroperoxy-lipids. We present arguments favoring the enzymatic mechanisms of ferroptotically engaged non-heme iron of 15-lipoxygenases (15-LOX) in complexes with phosphatidylethanolamine binding protein 1 (PEBP1) as a catalyst of highly selective and specific oxidation reactions of arachidonoyl- (AA) and adrenoyl-phosphatidylethanolamines (PE). We discuss possible role of iron chaperons as control mechanisms for guided iron delivery directly to their “protein clients” thus limiting non-enzymatic redox-cycling reactions. We also consider opportunities of loosely-bound iron to contribute to the production of pro-ferroptotic lipid oxidation products. Finally, we propose a two-stage iron-dependent mechanism for iron in ferroptosis by combining its catalytic role in the 15-LOX-driven production of 15-hydroperoxy-AA-PE (HOO-AA-PE) as well as possible involvement of loosely-bound iron in oxidative cleavage of HOO-AA-PE to oxidatively truncated electrophiles capable of attacking nucleophilic targets in yet to be identified proteins leading to cell demise.

      6. Quantification of microcystin-LR in human urine by immunocapture liquid chromatography tandem mass spectrometryExternal
        Wharton RE, Ojeda-Torres G, Cunningham B, Feyereisen MC, Hill KL, Abbott NL, Seymour C, Hill D, Lang J, Hamelin EI, Johnson RC.
        Chem Res Toxicol. 2018 Sep 17;31(9):898-903.

        Microcystins are toxins produced by many cyanobacteria species, which are often released into waterways during blue-green algal blooms in freshwater and marine habitats. The consumption of microcystin-contaminated water is a public health concern as these toxins are recognized tumor promoters and are hepatotoxic to humans and animals. A method to confirm human exposures to microcystins is needed; therefore, our laboratory has developed an immunocapture liquid chromatography tandem mass spectrometry (LC-MS/MS) method targeting the conserved adda portion of microcystins for the quantitation of a prevalent and highly toxic congener of microcystin, microcystin-LR (MC-LR). An acute exposure method was initially evaluated for accuracy and precision by analyzing calibrators and quality control (QC) samples ranging from 0.500 to 75.0 ng/mL in urine. All calibrators and QC samples characterized were within 15% of theoretical concentrations. An analysis of acutely exposed mouse urine samples using this method identified MC-LR levels from 10.7 to 33.9 ng/mL. Since human exposures are anticipated to result from low-dose or chronic exposures, a high-sensitivity method was validated with 20 calibration curves and QC samples ranging from 0.0100 to 7.50 ng/mL. Relative standard deviations (RSDs) and inaccuracies of these samples were within 15%, meeting United States Food and Drug Administration (FDA) guidelines for analytical methods, and the limit of detection was 0.00455 ng/mL. In conclusion, we have developed a method which can be used to address public health concerns by precisely and accurately measuring MC-LR in urine samples.

    • Maternal and Child Health
      1. Evaluating implementation of the Updated Care Considerations for Duchenne Muscular DystrophyExternal
        Ong KS, Kinnett K, Soelaeman R, Webb L, Bain JS, Martin AS, Westfield C, Bolen J, Street N.
        Pediatrics. 2018 Oct;142(Suppl 2):S118-s128.

        Care Considerations for Duchenne Muscular Dystrophy were published in 2010. However, little is known about the extent to which these considerations were implemented after publication. With this article, we provide direction on evaluating the uptake of the 2018 Duchenne Muscular Dystrophy Care Considerations. We identify key elements of care and present suggestions for their use in evaluation and research.

      2. [No abstract]

    • Nutritional Sciences
      1. Pilot randomized controlled trial of a Mediterranean diet or diet supplemented with fish oil, walnuts, and grape juice in overweight or obese US adultsExternal
        Jaacks LM, Sher S, Staercke C, Porkert M, Alexander WR, Jones DP, Vaccarino V, Ziegler TR, Quyyumi AA.
        BMC Nutr. 2018 ;4:26.

        Background: The 2015-2020 Dietary Guidelines for Americans recommend a Mediterranean-type diet as one of three healthful eating patterns. However, only one previous trial has evaluated the effects of a Mediterranean diet intervention in a US sample population. Methods: To address this gap, we conducted a pilot, non-blinded, 8-week randomized controlled trial on the comparative efficacy of consumption of a Mediterranean diet or a diet supplemented with fish oil, walnuts, and grape juice versus controls. Participants (overweight or obese US adults; 73% female and mean age 51 years) were randomly assigned to one of three groups: (1) Mediterranean diet; (2) habitual high-fat American-type diet supplemented with fish oil, walnuts, and grape juice; or (3) habitual high-fat American-type diet (controls). Intent-to-treat analysis of within-subject differences (Student’s paired t-test or Wilcoxon sign ranks test) and between-subject differences (mixed-effects models with a group-by-time interaction term, adjusted for baseline health outcome) was conducted. Results: Participants in the Mediterranean diet arm (n = 11) had significantly greater weight loss despite no significant change in total caloric intake, and lower plasma cystine, indicative of decreased oxidative stress, compared to controls (n = 9) at both 4 and 8 weeks. Compared to controls, they also had significantly lower total cholesterol and low-density lipoprotein cholesterol levels at 4 weeks. Participants in the supplement arm (n = 10) had significantly lower adiponectin levels compared to controls at 4 weeks. No significant improvements in endothelial function or inflammatory biomarkers were observed in either intervention group compared to controls. Conclusion: These results suggest that adopting a dietary pattern reflecting a Mediterranean diet improves weight and cardio-metabolic health among overweight or obese US adults, and may be more beneficial than supplementing habitual American diets with fish oil, walnuts, and grape juice.

    • Occupational Safety and Health
      1. [No abstract]

      2. Notes from the field: Lead exposures among employees at a bullet manufacturing company – Missouri, 2017External
        Jackson DA, Burr GA, Braun CR, de Perio MA.
        MMWR Morb Mortal Wkly Rep. 2018 Oct 5;67(39):1103.

        [No abstract]

      3. Rates of carpal tunnel syndrome in a state workers’ compensation information system, by industry and occupation – California, 2007-2014External
        Jackson R, Beckman J, Frederick M, Musolin K, Harrison R.
        MMWR Morb Mortal Wkly Rep. 2018 Oct 5;67(39):1094-1097.

        Carpal tunnel syndrome (CTS) occurs when the median nerve becomes compressed as it passes through the wrist within the carpal tunnel, resulting in pain, tingling, weakness, or numbness in the hand or the wrist. Occupational risk factors for CTS include engaging in work activities that require forceful, repetitive tasks, prolonged use of the hands or wrists in an awkward posture, or vibration (1). To assess trends and identify high-risk industries and occupations for CTS, the California Department of Public Health (CDPH) analyzed California workers’ compensation claims for CTS by industry (2007-2014) and occupation (2014) and calculated rates per full-time equivalent (FTE) worker. During 2007-2014, a total of 139,336 CTS cases were reported (incidence = 6.3 cases per 10,000 FTE) in California workers; the rate among women (8.2) was 3.3 times higher than that among men (2.5). Industries with the highest rates of CTS were textile, fabric finishing, and coating mills (44.9), apparel accessories and other apparel manufacturing (43.1), and animal slaughtering and processing (39.8). Industries with high rates of CTS should consider implementing intervention measures, including ergonomic evaluations and development of tools and instruments that require less repetition and force and that correct awkward postures.

      4. BACKGROUND: Exposure to patients’ blood/body fluids could be life-affecting, when providing care to patients with infectious diseases. Although the glove-gown interface is considered one of the weakest points of the protective ensemble system, there is a lack of research and existing standards do not provide much guidance on the strategies to minimize gaps between the gowns and gloves. Currently, there is no known standard test method to evaluate fluid leakage or assess performance improvements with new gowns/gloves. STUDY DESIGN: A novel test method with a robotic arm, which has the capability to simulate healthcare personnel’s arm movements during fluid exposures, was developed to determine the leakage at the glove-gown interface. This paper explains the test method and investigates the effect of movement, exposure type, exposure duration, procedure duration, and existence of pressure on the amount of leaked fluid at the glove-gown interface. RESULTS: Test results suggest that, with the exception of procedure duration, all parameters significantly affected the amount of fluid leaked at the glove-gown interface. Leakage was higher for soaking when compared to spraying, increased as the exposure duration increased, and was greater with the application of pressure. CONCLUSIONS: The novel method developed in this study could be used by manufacturers of personal protective equipment to evaluate their products. Standard development organizations could adapt this test method in their specifications, testing standards, and guidelines.

    • Parasitic Diseases
      1. Young adults in endemic areas: An untreated group in need of school-based preventive chemotherapy for schistosomiasis control and eliminationExternal
        Korir HK, Riner DK, Kavere E, Omondi A, Landry J, Kittur N, Ndombi EM, Ondigo BN, Secor WE, Karanja DM, Colley DG.
        Trop Med Infect Dis. 2018 Sep 5;3(3).

        Parasitologic surveys of young adults in college and university settings are not commonly done, even in areas known to be endemic for schistosomiasis and soil-transmitted helminths. We have done a survey of 291 students and staff at the Kisumu National Polytechnic in Kisumu, Kenya, using the stool microscopy Kato-Katz (KK) method and the urine point-of-care circulating cathodic antigen (POC-CCA) test. Based on three stools/two KK slides each, in the 208 participants for whom three consecutive stools were obtained, Schistosoma mansoni prevalence was 17.8%. When all 291 individuals were analyzed based on the first stool, as done by the national neglected tropical disease (NTD) program, and one urine POC-CCA assay (n = 276), the prevalence was 13.7% by KK and 23.2% by POC-CCA. Based on three stools, 2.5% of 208 participants had heavy S. mansoni infections (>/=400 eggs/gram feces), with heavy S. mansoni infections making up 13.5% of the S. mansoni cases. The prevalence of the soil-transmitted helminths (STH: Ascaris lumbricoides, Trichuris trichiura and hookworm) by three stools was 1.4%, 3.1%, and 4.1%, respectively, and by the first stool was 1.4%, 2.4% and 1.4%, respectively. This prevalence and intensity of infection with S. mansoni in a college setting warrants mass drug administration with praziquantel. This population of young adults is ‘in school’ and is both approachable and worthy of inclusion in national schistosomiasis control and elimination programs.

      2. Association of water quality with soil-transmitted helminthiasis and diarrhea in Nueva Santa Rosa, Guatemala, 2010External
        Matanock A, Lu X, Derado G, Cuellar VM, Juliao P, Alvarez M, Lopez B, Munoz F, Thornton A, Patel JC, Lopez G, Reyes L, Arvelo W, Blackstock AJ, Lindblade KA, Roy SL.
        J Water Health. 2018 Oct;16(5):724-736.

        Improved water quality reduces diarrhea, but the impact of improved water quality on Ascaris and Trichuris, soil-transmitted helminths (STH) conveyed by the fecal-oral route, is less well described. To assess water quality associations with diarrhea and STH, we conducted a cross-sectional survey in households of south-eastern Guatemala. Diarrhea was self-reported in the past week and month. STH was diagnosed by stool testing using a fecal parasite concentrator method. We explored associations between Escherichia coli-positive source water (water quality) and disease outcomes using survey logistic regression models. Overall, 732 persons lived in 167 households where water was tested. Of these, 79.4% (581/732) had E. coli-positive water, 7.9% (58/732) had diarrhea within the week, 14.1% (103/732) had diarrhea within the month, and 6.6% (36/545) tested positive for Ascaris or Trichuris, including 1% (6/536) who also reported diarrhea. Univariable analysis found a statistically significant association between water quality and STH (odds ratio [OR] = 5.1, 95% confidence interval [CI] = 1.1-24.5) but no association between water quality and diarrhea. Waterborne transmission and effects of water treatment on STH prevalence should be investigated further. If a causal relationship is found, practices such as household water treatment including filtration might be useful adjuncts to sanitation, hygiene, and deworming in STH control programs.

      3. When should the emphasis on schistosomiasis control move to elimination?External
        Secor WE, Colley DG.
        Trop Med Infect Dis. 2018 Aug 15;3(3).

        The stated goal of the World Health Organization’s program on schistosomiasis is paraphrased as follows: to control morbidity and eliminate transmission where feasible. Switching from a goal of controlling morbidity to interrupting transmission may well be currently feasible in some countries in the Caribbean, some areas in South America, northern Africa, and selected endemic areas in sub-Saharan Africa where there have been improvements in sanitation and access to clean water. However, in most of sub-Saharan Africa, where programmatic interventions still consist solely of annual mass drug administration, such a switch in strategies remains premature. There is a continued need for operational research on how best to reduce transmission to a point where interruption of transmission may be achievable. The level of infection at which it is feasible to transition from control to elimination must also be defined. In parallel, there is also a need to develop and evaluate approaches for achieving and validating elimination. There are currently neither evidence-based methods nor tools for breaking transmission or verifying that it has been accomplished. The basis for these statements stems from numerous studies that will be reviewed and summarized in this article; many, but not all of which were undertaken as part of SCORE, the Schistosomiasis Consortium for Operational Research and Evaluation.

    • Zoonotic and Vectorborne Diseases
      1. Notes from the field: Spatially associated coincident and noncoincident cases of La Crosse encephalitis – North Carolina, 2002-2017External
        Byrd BD, Williams CJ, Staples JE, Burkhalter KL, Savage HM, Doyle MS.
        MMWR Morb Mortal Wkly Rep. 2018 Oct 5;67(39):1104-1105.

        [No abstract]

      2. Knowledge and practices regarding Middle East Respiratory Syndrome Coronavirus among camel handlers in a Slaughterhouse, Kenya, 2015External
        Kamau E, Ongus J, Gitau G, Galgalo T, Lowther SA, Bitek A, Munyua P.
        Zoonoses Public Health. 2018 Sep 20.

        Dromedary camels are implicated as reservoirs for the zoonotic transmission of Middle East Respiratory Syndrome coronavirus (MERS-CoV) with the respiratory route thought to be the main mode of transmission. Knowledge and practices regarding MERS among herders, traders and slaughterhouse workers were assessed at Athi-River slaughterhouse, Kenya. Questionnaires were administered, and a check list was used to collect information on hygiene practices among slaughterhouse workers. Of 22 persons, all washed hands after handling camels, 82% wore gumboots, and 65% wore overalls/dustcoats. None of the workers wore gloves or facemasks during slaughter processes. Fourteen percent reported drinking raw camel milk; 90% were aware of zoonotic diseases with most reporting common ways of transmission as: eating improperly cooked meat (90%), drinking raw milk (68%) and slaughter processes (50%). Sixteen (73%) were unaware of MERS-CoV. Use of personal protective clothing to prevent direct contact with discharges and aerosols was lacking. Although few people working with camels were interviewed, those met at this centralized slaughterhouse lacked knowledge about MERS-CoV but were aware of zoonotic diseases and their transmission. These findings highlight need to disseminate information about MERS-CoV and enhance hygiene and biosafety practices among camel slaughterhouse workers to reduce opportunities for potential virus transmission.

      3. Inter- and intra-host sequence diversity reveal the emergence of viral variants during an overwintering epidemic caused by dengue virus serotype 2 in southern TaiwanExternal
        Ko HY, Li YT, Chao DY, Chang YC, Li ZT, Wang M, Kao CL, Wen TH, Shu PY, Chang GJ, King CC.
        PLoS Negl Trop Dis. 2018 Oct 4;12(10):e0006827.

        Purifying selection during dengue viral infection has been suggested as the driving force of viral evolution and the higher complexity of the intra-host quasi-species is thought to offer an adaptive advantage for arboviruses as they cycle between arthropod and vertebrate hosts. However, very few studies have been performed to investigate the viral genetic changes within (intra-host) and between (inter-host) humans in a spatio-temporal scale. Viruses of different serotypes from various countries imported to Taiwan cause annual outbreaks. During 2001-2003, two consecutive outbreaks were caused by dengue virus serotype 2 (DENV-2) and resulted in a larger-scale epidemic with more severe dengue cases in the following year. Phylogenetic analyses showed that the viruses from both events were similar and related to the 2001 DENV-2 isolate from the Philippines. We comprehensively analyzed viral sequences from representative dengue patients and identified three consensus genetic variants, group Ia, Ib and II, with different spatio-temporal population dynamics. The phylodynamic analysis suggested group Ib variants, characterized by lower genetic diversity, transmission rate, and intra-host variant numbers, might play the role of maintenance variants. The residential locations among the patients infected by group Ib variants were in the outer rim of case clusters throughout the 2001-2003 period whereas group Ia and II variants were located in the centers of case clusters, suggesting that group Ib viruses might serve as “sheltered overwintering” variants in an undefined ecological niche. Further deep sequencing of the viral envelope (E) gene directly from individual patient serum samples confirmed the emergence of variants belonging to three quasi-species (group Ia, Ib, and II) and the ancestral role of the viral variants in the latter phase of the 2001 outbreak contributed to the later, larger-scale epidemic beginning in 2002. These findings enhanced our understanding of increasing epidemic severity over time in the same epidemic area. It also highlights the importance of combining phylodynamic and deep sequencing analysis as surveillance tools for detecting dynamic changes in viral variants, particularly searching for and monitoring any specific viral subpopulation. Such subpopulations might have selection advantages in both fitness and transmissibility leading to increased epidemic severity.

      4. Travel and tick-borne diseases: Lyme disease and beyondExternal
        Parola P, Paddock CD.
        Travel Med Infect Dis. 2018 Sep 26.

        [No abstract]

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DISCLAIMER: Articles listed in the CDC Science Clips are selected by the Stephen B. Thacker CDC Library to provide current awareness of the public health literature. An article’s inclusion does not necessarily represent the views of the Centers for Disease Control and Prevention nor does it imply endorsement of the article’s methods or findings. CDC and DHHS assume no responsibility for the factual accuracy of the items presented. The selection, omission, or content of items does not imply any endorsement or other position taken by CDC or DHHS. Opinion, findings and conclusions expressed by the original authors of items included in the Clips, or persons quoted therein, are strictly their own and are in no way meant to represent the opinion or views of CDC or DHHS. References to publications, news sources, and non-CDC Websites are provided solely for informational purposes and do not imply endorsement by CDC or DHHS.

Page last reviewed: January 31, 2019